EMS is called to the residence of a 71 year old male for seizures.
On arrival the patient’s spouse meets the ambulance outside and hurries the paramedics along saying “Come quickly! Please help him!”
The paramedics arrive at the patient’s side just in time to see him receive an ICD shock.
They ask how long this had been going on.
“That was my 15th shock!”
The patient states that he “felt himself going faint” just prior to the first shock.
The cardiac monitor was attached and the following rhythm strips were recorded.
How would you proceed?
*** Update 08/22/2010 ***
The patient appears anxious.
Skin is pink, warm, and moist.
The patient has numerous skin tears in his arms which the spouse states are related to convulsions induced by the ICD shocks.
Vital signs are assessed.
Resp: 20
NIBP: 108/72
Pulse: 60 and irregular
SpO2: 98 on RA
Past medical history:
The EMS crew learns that this patient survived two sudden cardiac arrests prior to receiving his first ICD in 1992. The device was replaced in 2008. The patient does not have his device ID card but knows that it was made by St. Jude Medical.
Medications:
The patient states he takes several medications but he can only remember one of them: Coumadin.
The patient is placed on 100% oxygen.
The EMS crew contacts Online Medical Control and receives permission to apply a ring magnet to the device. The magnet is applied and taped in place. The tape doesn’t hold and a FF is assigned to hold the magnet over the device pocket.
A 12-lead ECG is captured.
And another.
The rhythm appears more stable on the monitor.
The patient is loaded for transport.
IV access is achieved.
En route the the hospital serial 12-lead ECGs are captured.
Vital signs are re-assessed.
Resp: 18
Pulse: 75 and slightly irregular
NIBP: 102/70
SpO2: 100 w/ oxygen via NRB @ 15 LPM
The patient feels much calmer and says, “Please don’t let that thing shock me again.”
This 12-lead ECG was captured on arrival at the hospital.
What do you think of the way this EMS crew handled the call?
What do you think the patient would say was the most important thing the EMS crew did for him?
See also:
Inappropriate or ineffective ICD shocks – Part I
Inappropriate or ineffective ICD shocks – Part II
shouldn’t the magnet placed turn off the pacer as well as the AICD? most magnets that are on rigs are not specific to just the ‘tachycardia therapy’. they normally shut the whole thing off. this pts underlying appears to be a-fib with a BBB. not truly convinced of the TdP. His pacer still appears functioning so Im not certain the magnet therapy worked at all. He may have a pacer lead that has migrated and double check lead placement and obvious causes of artifact. Im not so quick to jump on the mag bandwagon just yet. May consider if it reoccurs.
I did not have the energy to read all the post, so I hope I not repeating. I treated a similar patient, we hung 150mg of Amio and ran it over 10min. It worked extremly well. It doesn’t look like the medics gave aspirin. ASA is the best medication we have in the case of MI(decreases morbidity and mortality by 60%). This person obviously has cardiac damage hints the vtach causing his ICD to fire.
Amy K. -
Magnet application should not affect the bradycardia functions of an ICD. If that were the case, a pacemaker dependent patient could die if they wandered into a magnetic field. So the pacemaker would need to be turned off by RF telemetry (being hooked up to a laptop computer and specifically told to turn off — probably complete with a “ARE YOU SURE YOU WANT TO DO THAT?” screen). The worst that should happen is that a pacemaker (without an ICD) would convert to a more primitive mode. For example, switch from DDD to DOO (dual chambered pacing at a fixed rate without inhibition). So in most cases magnet application will only affect the tachy therapy of an ICD but you should ask to see the patient’s ID card and read the back.
Tom
Tom –
I’m not against ASA for this patient (although I’m not convinced he’s having a heart attack). As for the mortality benefit of ASA for acute STEMI I think it’s more along the lines of 25% according to ISIS-2. Update: Here’s the language from the abstract: “[A]spirin alone … produced a highly significant reduction in 5-week vascular mortality: (9.4%) vascular deaths among patients allocated aspirin tablets vs 1016/8600 (11.8%) among those allocated placebo tablets (odds reduction: 23% SD 4; 2p less than 0.00001).”
http://www.ncbi.nlm.nih.gov/pubmed/2899772
Tom
Great case! First look I saw also looked like there might be some polymorphic vtach… If I had a magnet I would certainly try it, to get a clearer rhythm strip. This did bring up a question for me, can you get post shock cardiac dysfunction from an ICD?
In the absence of a magnet, I would try the mag, then lido or amiodarone. I agree amio is sketchy with qt prolonging effects, but I wonder if giving mag with no resolution would exclude a diagnosis of TdP. Any thoughts?
If I was able to, and the pressure was good, I might give a whiff of versed or if I was a little more concerned maybe some fentanyl for pure analgesia.
Putting on external pads would also be top of the list along with general supportive care (o2 iv etc).
If I was unable to get a clean 12 lead, I would also consider ASA as it is unlikely to harm, and an MI might be the underlying cause of the arrhythmia.
Interesting case. Working my days off in a Heart ER I have sen cases like this many times and cardiologists generally approach them the same.
Step 1, apply the magnet, but be sure to be ready to remove it when the pt goes unconscious.
Step 2, IV, 12-lead, o2, amiodarone bolus, something for pain
Step 3, if the amnio doesn’t work have seen a variety of other drugs (lido, mag, and even ready recently about someone getting bretylium as a last resort which worked).
Usually the cause of these events is the pt stopped taking their home amnio.
Definitely agree with an amio or lido drip, further more agree with tom’s idea of “ARE YOU SURE YOU WANT TO DO THAT”. I might transmit the 12-lead and get a second opinion
-no magnets in my system.
-Pads out and ready
-02 maintaint sp02 above 96%, 12 leads xserial, IV x2 if poss, NS hung and 150ml/hr at this time.
-Consult med cont
-He is likely going to receive more shocks in my care,
-Sedate- versed, or a narcotic. I am not allowed to combine the two in my system. Ill prolly request it via cell phone anyway. And i think benzo and pain managment are both required but what do i know.
-I thought it looked more polymorphic so i was tempted for mag as first line. However after reading above perhaps this is careless and amioderone 150mg over 10 is better indicated first line? I know it generally has possitive effects on ventricular rhythms, and in this case if patient is on Dig i dont mind messing up his values if we can fix the bigger problem, the hospital can fix the dig